ML17055E009

on the plant simulator,

human factors

analysis of the

on-going evaluation

program for EOPs,

gA measures,

training activities,

and

an evaluation of the containment venting provisions.

Unit 2 - Evaluation of an operating

crew on the plant - referenced

simulator.

Results:

See Executive

Summary in report.

SS07200195

SS070S

PDR

ADOCK 05000220

9

PDC

CB

1.0

Executive

Summar

DETAILS

~Back round

Following the Three Mile Island (TMI) accident,

the Office of Nuclear

Reactor

Regulation

developed

the "TMI Action Plan"

(NUREG-0660

and

NUREG-0737) which required licensees

of operating reactors

to

reanalyze

transients

and accidents

and to upgrade

emergency

operating

procedures

(EOPs) (Item I.C. 1).

The plan also required

th'e

NRC staff

to develop

a long-term plan that integrated

and expanded efforts in

the writing, reviewing,

and monitoring the plant procedures

( Item

I.C.9).

NUREG-0899, "Guidelines for the Preparation

of Emergency

Operating

Procedures,"

represents

the

NRC staff's

long-term program

for upgrading

and describes

the

us'e of a "Procedures

Generation

Package"

(PGP) to prepare

The licensees

formed four vendor

type owner groups corresponding

to the four major reactor types in

the United States;

Westinghouse,

General Electric,

Babcock 5 Wilcox,

and Combustion

Engineering.

Working with the vendor

company

and the

NRC, these

owner groups developed

Generic Technical

Guidelines

(GTGs)

which are generic

procedures

that set forth the desired accident

mitigation strategy.

These

GTGs were to be used

by the licensee

in

developing their

PGP.

Submittal of the

PGP was

made

a requirement

by

Confirmatory Order dated

June

12,

1984.

Generic Letter 82-33,

"Supplement

1 to NUREG-0737

Requirements

for Emergency

Response

Capability" requires

each licensee

to submit to the

NRC

a

PGP which

includes:

Plant-specific technical

guidelines with justification for

differences

from the

GTG

(ii)

A writer's guide

(iii)

A description of the program to be used for the validation

of EOPs

(iv)

A description of the training program for the upgraded

From this

PGP, plant specific

EOPs were to have

been

developed that

would provide the operator with directions to mitigate the

consequences

of a broad

range of accidents

and multiple equipment

failures.

Due to various circumstances,

there were long delays

in achieving

NRC

approval of many of the

PGPs.

Nevertheless,

the licensees

have

implemented their EOPs.

To determine

the success

of the

implementation,

a series of NRC inspections

are being performed to

examine the final product of the program,

the

I

On June

20-24,

1988

an

NRC team of inspectors

consisting of two

reactor

inspector s,

a reactor

system consultant,

an operating

licensing examiner/inspector,

two human factor specialists,

and the

resident

inspector conducted

an inspection of the

Emergency Operating

Procedures

at the Nine Mile Point Unit

1 facility.

Nine Mile Point

Unit

1 is

BWR-2 with a Mark

1 containment.

The objectives of the

team were to determine if:

The

EOPs are technically correct,

the

can

be physically car ried-out in the plant,

and that the

can

be performed

by the plant.=staff.

The objectives

would be considered

to be met if review of the

following areas

were found to be adequate:

comparison of the

with the plant specific technical

guidelines

(PSTG)

and the

BWR

owners

group emergency

procedure

guidelines

(EPG), review of the

technical

adequacy of the deviations

from the

EPG, control

room and

plant walkdowns of the

real time evaluation of the

on the

plant simulator, evaluation of the licensee

program

on conti'nuing

improvement of the

and performance

of human factor analysis of

the

~

The inspection

focused

on the adequacy of the product and

did not depend

on the review of the process

to develop

the

If

any of the areas

were not found to be acceptable

the inspection

would

assess

other. areas

as necessary

to understand

the. basis for the

deficiencies.

In this inspection

the walkdowns of the procedures

and the

EOP usage

in the simulator were found to be deficient therefore.

a review of the

validation and verification activities,

a review of the training

activities associated

with EOPs,

as well as

an assessment

of the Unit

2 operator s use of the

was done.

In addition,

containment

venting provisions were specifically reviewed.

Containment 'venting

provisions for all

BWRs with Mark

1 containments

are being performed

across

the country as

an

NRC inspection initiative.

At Nine Mile Point-1 the facility is in the final stages

of

converting the existing approved

and implemented text version

into flow charts.,The

current version of EOPs are

based

on revision

4ac of the

BWR Owners

Group Emergency

Procedure

Guidelines

(EPGs).

The facility is using the

same version of the

EPGs for the flow

charts.

This inspection

focused

much of the resources

into the

flowcharts since the facility plans'o

implement the flowcharts in

the near future. Operators

have

been training

on the flowcharts

exclusively for about

one year.

Text procedures

were assessed

during

the technical

adequacy

determination

as well as during the simulator

assessment.

Conclusions

Section

4 of the inspection report addresses

the technical

adequacy

determination of the

NMP-1 EOPs.

The team concluded that the

were generally technically adequate.

There are

a few items that have

to be resolved

by the licensee for assurance

that the procedures

are

consistent with the technical guidelines.

The principal item of

concern

in this area is the

number of procedures

referenced

in the

EOPs that do not carry out the actions listed in the

EOPs, that

no

longer exist or that include values which do not agree with those

values in the

Followup of this item indicates that the facility

does not have adequate

administrative controls to assure that

procedures

referenced

in the

EOPs are not revised without first

assessing

the impact

on the

(Unresolved

item 50-220/88-22-01)

The control

room and plant walkdowns are discussed

in Section

5.

The

team concluded that the facility had not done

an adequate

job in

pre-planning

those activities necessary

to carry out the

EOP actions,

had not done

a formal plant walkdown of the procedures

and

had not

assured

that the tools, material

and equipment

are available to carry

out the

EOP required tasks.

Therefore,

an assurance

does

not exist

that the

EOP required actions

in the plant can

be carried out.

In

addition,

the lack of distinct labeling for EOP equipment

hampered

facility personnel

for some

EOP related

ta'sks.

The facility indicated

that the

detailed

control

room design

review

should address

the

other inconsistencies

noted in the plant labeling but

a item by item

comparison

was not done.

(Unresolved

item 50-220/88-22-02)

The simulator portion of the inspection is discussed

in Section

6.

The team concluded,

without reservation,

that the operating staff was

unable to use the flow charts

or the text version of the. EOPs.

The

team observed deficiencies

in three areas:

an apparent

misunderstanding

regarding

emergency

operating

concepts;

procedure

adherence;

and use of the procedures.

The team concluded that

.licensed

operators

were deficient in the following areas:

a

fundamental

understanding

of the

EOPs;

a fundamental

understanding

of

accident mitigation strategies;

and

an ability to implement the

In addition, while not part of the

EOP assessment,

teamwork and

communication skills needed

to be improved

as well as the recognition

of emergency

system status

and degraded

plant conditions.

Because

of

the widespread

observations,

the inspectors

did not consider

the

observations

to be of an individual nature but reflected

a

programatic deficiency. Additional information which describes

the

training effectiveness

evaluation is discussed

in the quality

measures

assessment

in Section

9 and in the training assessment

in

Section

12 of this report.

(Unresolved

items 50-220/88-22-06,

50-220/88-22".08)

The

human factors

assessment

of the flow chart version of the

EOPs is

discussed

in Section

7. This assessment

concluded that in general

the

EOPs are high quality procedures

with an appropriate

level, of detail

and

a clearly designed

format.

However, in spite of the high quality,

the

do contain

a number of weaknesses

in areas

that have

a

strong relationship to potential

human error.

The items are

relatively few in number

and easily corrected.

(Unresolved

item

50"220/88-22"03)

k

In Section

8 the

team concluded that the on-going evaluation

program

for EOPs

was weak and-unstructured

to ensure quality

EOPs are

maintained

and modified as necessary

based

on plant experience

and

use, training,

and plant modifications.

(Unresolved

item

50"220/88"22"04)

A deficiency in the

EOP program was

a lack of quality assurance

involvement. This is discussed

in Section

9 of the report

and is

based, in part,

on the facility administrative

procedure

which

excludes

QA involvement in EOPs.

(Unresolved

item 50-220/88-22-05)

The quality assurance

section also describes

a recent

QA identified

issue which questions

the quality of the training provided to both

the Unit

1 and

2 operators

based

on the lack of quality requirements

included in the purchase

of the training services.

This

QA finding

warrants facility management

immediate attention.

(Unresolved

item

50-220/88-22-06)

The containment venting requirements

in the

EOPs are discussed

in

Section

10.

The draft procedure

reviewed appeared

to adequately

describe

the steps

needed to vent the containment

under emergency

conditions.

However,

numerous

comments

and errors were identified

that require resolution before it is issued.

The inspectors

reviewed the licensee

actions during the

validation

and verification process.

The validation and verification

within the control

room appeared

to be adequate

and fairly complete.

However the verification and validation activities'id not adequately

use

a multidisciplined team approach,

the validation did not include

non-control

room actions

in the

and the verification did not

address

the correspondence

of plant hardware with procedures

as

was

indicated to be

a part of the program.

This is further discussed

in

Section ll.

(Unresolved

item 50-220/88-22-07)

Section

12 of the report discusses

the findings of an assessment

of

the operator training

on

The lesson

plans

appear

to be

complete

and adequate.'owever

the deficiecies

in the knowledge

and

use of the

EOPs suggest

weakness

in one or more of the following

areas:

instructor qualification, frequency

and duration of EOP

training or implementation of the lesson

plans.

(Unresolved

item

50-220/88-22-08)

An assessment

of the ability of a Unit-2 operating

crew to use the

Unit-2 EOPs

was performed using the plant-referenced

simulator.

The

current day shift operating

crew was utilized at the

end of their day

shift to perform the assessment.

The scenarios

chosen

by the team

were essentially identical to those

used at Unit-1, only substituting

plant specific equipment.

No fundamental

weaknesses

were observed

regarding

the Unit-2 operators.

2.0

Persons

Contacted

Nia ara

Mohawk Com an

and Contractors

+R.

"H.

K.

+M.

W

D.

AC

AJ

N

'R.

AT

"K.

J.

+R.

p

yAJ

K.

A.

Abbott, Unit 2 Station Superintendent

Agarwal,

Lead Engineer,

Site Licensing

Barrett, Assistant Operations

Superintendent

Belvin, Assistant Senior Shift Supervisor

Coulumb, Unit 2 Senior Shift Supervisor

Drews, Technical

Superintendent

Lilly, Senior Shift Supervisor

Mangan,

Senior

Vice President

Parrish,

Senior Shift Superintendent

Perry,

Vice President,

Quality Assurance

Rademacher,

Director Regulatory

Compliance

Randall,

Operations

Superintendent,

Unit I

Roman, Unit

1 Station Superintendent

Ross,

Project Manager," OEI

Sheahar,

EOP Engineer

Siegler, Assistant Senior Shift Supervisor

Smith, Unit 2 Operations

Superintendent

Thomas,

Corporate

Licensing

Wilde, Quality Assurance

Surveillance

Supervisor

Willis, General

Superintendent

Zollitsh, Training Superintendent

Zollnick, Assistant to SeniorVice President

New York State

"P.

Eddy, Public Service

Commission

U.

S. Nuclear

Re ulator

Commission

~R. Gallo, Chief Operations

Branch,

Region I

D. Lange, 'Chief

BWR Section,

Region I

"Denotes those

present at the exit interview conducted

on June

24,

1988

+Denotes

those

present at Unit 2 simulator session briefing.

The inspectors

also contacted

other

members of the licensee

operation

and

technical staff.

3.0

Basic

EOP/BWR Owners

Grou

EPG

Com arison

A comparison of the facility EOPs

and the

BWR Owners

Group Emergency

Procedure

Guidelines

(EPGs) Revision

4ac

was conducted

to ensure that the

licensee

has developed

the procedures

indicated in the

EPGs.

The

reviewed are listed in Attachment

A of this report.

This facility EOPs

are in agreement

with the

EPGs

on the type of procedures

required to

respond

to symptoms which result in entry into these

procedures.

4.0

Inde endent Technical

Ade uac

Review of the

Emer ency 0 eratin

Procedures

The Nine Mile Point

1

EOPs in Attachment

A were reviewed to assure

that

the procedures

are technically adequate

and accurately

incorporate

the

BMR

Owner's

Group

EPGs.

A comparison of the Plant Specific Technical

Guidelines

(PSTG) to the

EPG and

was also performed.

Differences

between

the

EPG and

PSTG were assessed

for adequate

technical

justification.

Selected

specific values

from the procedures

were reviewed

to determine that the values

were correct.

~pindin s:

4. 1

Technical

Basis for Parameters

Used in

The

PSTG Primary Containment

Pressure

Control section,

step

PC/P-2

states, "If torus pressure

exceeds

18 psig (Torus Spray Initiation

Pressure)

but only if drywell temperature

and pressure

are within the

Containment

Spray Initiation Limits (Figure 5), shut

down

recirculation

pumps

and drywell cooling fans

and initiate containment

sprays."

In step 6.2 of the flow chart and text procedures,

the

licensee

has substituted

a

~dr well pressure

of 18 psig for the torus

pressure

which is the parameter of concern:

The licensee

stated that

the change

from torus to drywell was accomplished

because

the torus

pressure

gage only reads

to 4 psig

~

The licensee

was unable to

provide adequate

calculations

and rationale

in its technical

basis

document for the selection of a drywell pressure

of 18 psig.

In the

PSTG Primary Containment

Torus Mater Level Control section,

step

SP/L-2 (mini'mum torus water level

LCO) calls for the maintenance

of torus water level

above the Heat

Ca acit

Level Limit

Curve

Fi ure

8

.

The licensee

s

have eliminated the

use of

this curve

and substituted

a fixed level limit of 7 feet.

The

justification for the elimination of the Heat Capacity

Level Limit,

curve

and the substituted

methodology

does

not appear

in the

licensee's

technical

basis

document.

4.2

Procedures

Referenced

in

The licensee's

4 flow chart directs the operator to take action

in several

referenced

procedures.

Three of these

procedures

were

found to be incorrect.

In procedure

OP-14,

step 6.3 (flow chart step

7)

no longer exists.

The proper reference

should

be OP-14,

step G.3.

In procedure

OP-2, (also step 7), step H.21.d is referenced.

The

latest revision of OP-2 does

not contain this step

and during

a prior

revision, the action which the operator is directed .to accomplish

(add water to the torus)

was eliminated (from OP-2).

Procedure

PSP

13 is referenced

in the Hydrogen

and Oxygen monitoring and control

section of EOP 4.

This procedure

was superseded

in August of 1986 by

procedure

Nl-CSP-13A,

"Sample

and Analysis of Reactor

Water and

Containment

Gas Using the

PASS," which is now in its third revision.

Procedure

N1-CSP-13A requires that the Control

Room open four valves

upon request of the .chemist

who will take the

PASS sample.

This step

cannot

be accomplished

by Control

Room operators.

There is

a single

valve operator

which opens

8 valves in System

11 (which is being

lined up in accordance

with the procedure).

Only two of these

valves

are included

among the valves requested

to be opened.

The other

two

valves could not be identified by the Control

Room operators.

It was

apparent

to the inspector

and to the operators that this portion of

procedure

Nl-CSP-13A had not been validated

by a walkdown.

Based

on findings for procedure

inconsistencies

and:other findings

identified during the walkthrough, the inspector

inquired if

procedures

referenced

or interfacing with the

EOPs are assessed

against

the

EOPs before being modified.

A review of AP-2 "Production

and Control of Procedures"

did not identify sufficient controls to

assure

procedures

referenced

by EOPs are not changed without

assessing

the

EOPs for possible

impact.

Facility actions

are

needed

'to assure

adequate

administrative control.

Facility actions to

resolve technical

adequacy

concerns will be tracked

as unresolved

item 220/88-22-01.

5.0

Control

Room and Plant Malkdowns

The inspectors

walked down the

and procedures

referenced

therein to

confirm that the procedures

can

be implemented.

The purpose of the

walkdowns was to verify that instruments

and controls contained or

required to be used to implement the procedures

are consistent with the

installed plant equipment,

insure that the indicators, controls,

annunciator s referenced

in the procedures

are available to the operator,

and ensure that the task can

be accomplished.

Detailed

comments identified

are also noted in Attachment

B. General

comments,

observations

and

conclusions

from the detailed

comments

are discussed

below.

The walkdowns identified a general

inconsistency

in the plant labeling.

There were differences with the procedure

names

and plant labels.

Gages

were not always labeled.

Soqetimes

the plant label referred to

a

name

and

sometimes

referred to

a

numbers.

The facility indicated that actions

resulting

from the detailed control

room design

review would respond to

many of these

observations.

The team observed

a general

lack'of distinct labeling for EOP related

instruments

and equipment.

There

was

no clear distinction between

instruments that relate to the

and those that do not.

The facility did not have

any pre-staged

storage

of equipment,

tools, or

jumpers necessary

to accomplish

EOP required tasks but only planned

on

using tools that are generally available

on site.

The facility walkdown

of EOPs

and procedures

referenced

in the

had not been

done to assure

that the procedures

can

be accomplished,

as evidenced

by: the lack of

adequate

boron

on site to accomplish alternate

boron injection, the lack

of physical

methods to add the boron to the tank, the lack of the controls

0

necessary

to accomplish

the containment

sampling activities,

the

inaccessibility of plant equipment

in the overhead,

the difficulty in

locating

some

EOP related electrical

equipment,

and the lack of

information to indicate

some of the

EOP entry conditions in Secondary

Containment Control.

The team concluded that because

of the general

lack of adequate

preplanning to carry out the

the facility could not demonstrate

that

the

EOPs could be carried out in the plant.

Facility actions to resolve

items generated

during the walkdown will be tracked

as unresolved

item

220/88-22-02.

6.0

Simulator

Six scenarios

were conducted

on the plant specific simulator

using

a

normal shift crew.

The simulator scenarios

provided information

on real

time activities.

The purposes

of this exercise

were to determine that the

EOPs provide operators with sufficient guidance

such that their responsi-

bilitiess

and required actions during the emergencies

both individually and

-

as

a team are clearly outlined; verify that the procedures

do not cause

operators

to physically interfere with each other while performing the

and verify that the procedures

did not duplicate operator actions

unless

required (i.e.

independent verification).

In addition,

when

a

transition

from one

EOP to another

EOP or other procedure

is required,

precautions

are taken to ensure that all necessary

steps,

prerequisites,

and initial conditions,

are

met or completed

and that the operators

are

knowledgeable

about where to enter

and exit the procedure.

The scenarios

were consistent with those

used during previous

i'nspections,

and were designed to evaluate

the

This evaluation

includes operator

knowledge of the

EOP concepts

and the usability of the

procedures

by the operators,

not an evaluation of individual Reactor

Operator

(RO) and Senior Reactor Operator

(SRO) performance.

From observations

during the scenarios,

and detailed discussions

with the

operating staff following each scenario,

the

team identified fundamental

deficiencies

in three areas.

An apparent

misunderstanding

regarding

emergency

operating concepts,

procedure

adherence,

and

a misunderstanding

regarding

the

use of the flowchart and text EOPs.,

1.

Regarding

emergency

operating

concepts,

the

NRC team identified

a

lack of understanding

by the operating

crew in the following specific

areas:

The band to control

RPV pressure,

and the meaning of (ERV)

Electromatic Relief Valve cycling.

The need to sequence

single

ERVs when multiple single

ERV operation

is required.

10

Understanding

the basis of waiting until

RPV level is at top of

active fuel prior to emergency depresurization.

Understanding

containment control importance,

especially during

an

ATWS.

Need for alternate

water injection systems

only when required.

When

RPV water level

can

or cannot

be determined.

2.

Regarding

procedure

adherence,

the

NRC team identified

a lack of

understanding

by the operating

crew in the following specific areas:

Verification of the status of safety-related

equipment.

Locking out of Core Spray

pumps not required to assure

adequate

core

cooling.

What to do if a step cannot

be accomplished.

Use of the Level/Power control procedure.

Concurrent

use of more than

one procedure.

Concur rent execution of all legs within a procedure.

3.

Regarding

the use of flowcharts

and text procedures,

the

NRC team

observed

performance deficiencies

by the operating

crew in the

following specific areas;

Unfamiliarity with the text procedures.

Decision steps

were being

used

as action steps.

Steps

in the procedures

were missed.

I

Steps

required to be executed

concurrently were not completed.

Placekeeping

techniques

were not used during implementation of the

Transitions

from one

EOP to another

were missed.

Unfamiliarity on when to enter

and exit the

Procedures

required to be executed

concurrently were not

accomplished.

11

The team concluded that the operating

crew was unable to use the

flowchart

EOPs or the existing text

This conclusion

was

reached

by the

NRC team from observations

made,

and detailed

discussions

held with the operating

crew following each scenario.

The

NRC team determined that:

1.

A fundamental

understanding

of the

was lacking.

2.

A fundamental

understanding

of accident mitigation strategies

was lacking.

3.

The ability to implement the

was lacking.

4.

Teamwork and communciations,

while not an assessment

criteria

was not evident.

5.

The ability to recognize

emergency

systems

status

was deficient.

6.

The ability to recognize

degraded

plant conditions

was

deficient.

7.0

Human Factors

Review of the

NMP-1 Emer enc

0 ertin

Procedures

As

a result of the

human factors review of the Nine Mile Point Nuclear

Station Unit

1 EOPs,

a list of concerns

has

been

generated

(see Attachment

C).

An initial desktop

review of the

was conducted prior to the

on-site inspection.

Observation of simulator exercises,

interviews with

NMP-1 staff,

and plant walkdowns were

used to both corroborate

those

items

noted during the desktop

review and to identify additional

concerns.

Because

NMP-1 expects to have final approval

on the flowchart version of

the

EOPs in the near future the following comments

are based

on the

flowchart EOPs.

In cases

where

comments refer to the

NMP-1 text EOPs,

explicit reference

to the text version is made.

Ip general,

the

NMP-1

EOPs are high quality procedures

with an appropriate

level of detail

and

a clearly designed

format.

They should provide

operators with easily understandable,

highly useable

support in perfor-

mance of their duties during mitigation of the consequences

of a range of

accidents

and equipment failures.

However, despite th'eir general

high

quality,

a number of weaknesses

have

been identified in the

NMP-1 EOPs.

These

weaknesses

are of particular concern

because

they fall into

Other Documents

and

N1-OP-2

N1-OP-14

N1-OP"9

N1 "OS I-3

AP-2 '

Nl-SOP-1

Nl-SOP-3

Procedures

Core Spray System,

Revision

17 effective 3/19/88 with

changes

through 5/18/88

Containment

Spray

System

Nos.

80 & 93, Revision

27

effective .6/16/86 with changes

through 9/8/87

Nitrogen Inerting and H2-02 Monitoring Systems for the

Primary Containment

and Pressure

Suppression

System,

Revision

15 effective 6/10/86

Production

and Control

NMI1 Emergency Operating

Procedure

Revisions,

Revision

0 effective 6/6/88

Production

and Control of Procedures,

Revision

9 effective

3/4/88

Reactor

Scram Revision

0 dated 6/1/86

Alternate Control

Rod Insertion, draft. dated

June. 88

Attachment

A

N1-OP-5

Nl-OP-12

N1"OP-21

Cont'rol

Rod Drive System,

Revision

23 (Section G.26)

Liquid Poison

System,

Revision

16 (Section

H.4)

~ Fire Protection

System,

Revision

12 (Section G.6.a)

Letter T.

Lempges

to. D. Vassallo,

"NMP-1 Procedure

Generation

Package"

dated

3/1/84

Letter C.

Mangan to J. Zwolinski "NMP-1 Revised Writers Guide, Plant Specific

Technical Guidelines

and Revision

1 of the Training Description" dated 4/18/86

Letter C.

Mangan to

USNRC "NMP-1

EOP Verification Program

Plan

and Validation

Program Plan" dated 3/3/87

0

ATTACHMENT 8

Detailed Malkdown Comments

Nl-EOP-2

RPV Control

A general

inconsistency

was noted with the valve labeling in the

NMP-1

control

room.

Some,

but not all, valves

have valve number labels to go

with the valve title labels.

Most valve number labels were located

above

the associated

valve status lights, but

some were noted to be located

below the valve control switches.

2.

3 ~

4.

..

Figure 2. 1, Core Spray

Pump

NPSH Limit, is

a graph of torus temperature

('F) versus

core

spray

pump flow (1bm/hr).

The torus water temperature

meter in the control

room ranges

up to 230

F.

Torus temperature

on Figure

2. 1 curves

up to 250~F.

The control

room meter cannot

measure

temperature

over 230 F.

The value to read for "torus overpressure"

was not clear to

operators.

Different areas of the graph are

shaded

in Figure 2. 1 in the

flowcharts

and text procedures.

On the graph,

the

pump flow engineering

units are

1bm/hr, the control

room meter is labeled 1b/hr.

Step 4. 1 asks, "Is any

ERV cycling?"

The referenced

valves are labeled

"Power Operated. Relief Valve (Electromatic)," not ERV's.

Step 3.3. 1 states,

"Place the

ADS inhibit Switch in Bypass."

The bypass

switches

are not labeled in the control

room.

In step 3.2 (and other places),

the procedure

section

numbers

were not

listed in OP-2

and OP-12.

N1-EOP-3

Failure to Scram

EPG step

RC/g-5 ( similar to step 6.3 of EOP-3) states, "If ARI has not

initiated, initiate ARI."

This step is repeated

in

EPG step

RC/g-2.

The

licensee

step 6.3 is in a different logic location than would be required

by the

EPG.

2.

EPG step

RC/g-1 states,

"Confirm or place the reactor

mode switch in

shutdown."

Nl-SOP-1,

Reactor

Scram Procedure,

instructs

the operator to

place the reactor

mode switch in refuel position.

EOP-3 does not agree

with SOP"1.

EOP-4

Primar

Containment Control

Step 4.4 calls for the operator to verify that

3

ERVs are open.

The Relief

valves are actually labeled

"Power Operated Relief Valves (Electromotive)"

on the panel.

2.

Step 5.2 has

a statement

requiring the operator to take action before

drywell temperature

reaches

300 ~F.

There are several

possible

methods to

read this temperature.

The proper methodology to be used to obtain the

re'ading

should

be indicated to the operator.

Attachment

B

3..

Table 4. 1 indicates

terminal blocks which must be jumpered to bypass

containment isolation.

These terminal connections

are not identified in

any special

manner to indicate that they are,EOP related (color coded,

tagged, etc,).

The jumpers which are to be used to perform this function

are also not controlled for exclusive

EOP use.

When additional jumpering

requirements

are considered,

the four jumpers sighted in the control

room

are not sufficient for

EOP use.

In N1-0P-14,

Containment

Spray System,

a procedure

referenced

in EOP-4,

valve BV-93-65, which must be operated

in the plant, is located in an

inaccessible

location about

12 ft. above the floor.

A means to operate

the valve when required during the execution of the

EOPs should

be

provided.

5.

N1-0P-9,

Special

Procedure,

Venting Primary Containment

through Reactor

Building Emergency Ventilation System Ouring Normal Operating Conditions

is

a procedure

referenced

in EOP-4.

It was noted that most valves which

were called out in the procedure

are labeled differently in the control

room,

and

some valves

have

no numbers

on the panel at all (step

G. I.a.3)

and 4).

In step

G. I.a.5) the local station

near

valve SSI¹2

has

two

pressure

gages.

The procedure

does

not identify which is to be read.

The

method of communication

between this station

and the contro'1

room is not

specified nor i't apparent.

EOP"5

Secondar

Containment Control

The entry condition for differential pressure

is to be "at or above

0 in.

of water".

The gage installed for this purpose

can not be read

above

0

in.

as "0" is

a pegged position

on the gage.

The gage is not labeled

as

to function or that it reads

negative

prcssure'.

3,

In Table 5. 1, the area temperature

in the

EC Condensate

Return Valve Area

for ISOL VALVE 39-06 is given as

168 'F.

In OP-13,

which contains

the

annunciator

response

procedure, it is given as

174 'F.

In Table 5.2, the set points listed do not correspond

in all cases

with

the actual

set points of the instruments

as determined

from the labels

on

the indicators.

As an example,

the area radiation level for containment

spray

HX area is listed as

5 mr/hr in table 5.2 and

as

20 mr/hr on the

meter.

4.

A review of procedure

Nl-OP-53, which is the procedure

in which the

annunciator

alarm responses

for the

sump alarms

in

EOP Table

5 '

are

located,

indicated

a lack of locations of the alarmed points.

The

locations are,

however,

indicated in the

EOP.

Sump ¹12

(SW corner area)

had at least

3" of water in it at the time of this inspection.

The alarm

set point is 3".

Sump ¹11

(NW corner area) is covered with a bolted plate

which does not allow sump level to be visually inspected.

5.

Attachment

B

In all tables in EOP-5,

which specify annunicator

location,

a review of

the annunciator

response

procedures

reveal that none of the annunciator

response

procedures

cross reference

the

The licensee

explained that

these

references

are being added

when the annunicator

response

procedures

(actually contained

as

a portion of the related

system's

OP)

comes

up for

review.

This review occurs

every two years.

All annunciator

response

proce'dures

referenced

in the

EOPs require up-dating.

In Table 5.4, the maximum safe operating water levels (which are not

annunciated

points) are not indicated in any manner in the

Pump

Compartments.

This could be easily identified with a painted level line

on the Compartment wall.

During visual inspection, it appeared

to the

inspector that the

max safe operating water levels of 6'nd 7're too

high.

The

pump motors would appear to be grounded

out at

a lower water

level.

Nl-EOP-7

8PV Fl oodin

Steps

2.4 and 3.3 states,

"Place the Motor'eedwater

Pump High Level Trip

Bypass Switch on Panel

F in Bypass."

Two switches

have to be placed

in

bypass (for pumps

11 and 12), not one,

as implied by the wording of the

steps.

The words "Reactor

Head Vent" should

be "Reactor Vessel

Vent Valves" to

agree with nameplate

engraving

and

number of valves,

in steps

2. 1.4.2

and

3. 1.3.2.

Also "EC Vent to Torus" should

be

"EC Vent to Torus Valves" to

agree with the

number of v'alves to be repositioned.

This comment also

applies

to step

1.4 in Nl-EOP-8.

Nl-EOP-8

Emer enc

RPV De ressurization

2.

Step

1 '

states,

"Is RPV pressure

greater

than

50 psi

above torus

pressure?"

The torus pressure

meter range is 0-4 psig.

The use of the

torus pressure

meter

may not be acceptable

under certain conditions

(>4

psig torus pressure)

to answer

the question.

Step

1. 1 asks, "Is drywell pressure

at or above 3.5 psig?"

The drywell

pressure

meter in the control

room is labeled

in engineering

units of psi,

not psig.

Nl-EOP-10

Dr well Floodin

Numerous discrepancies

between

valve nameplate

labels in the control

room

and

EOP-10 wording were noted

( steps

1. 1, 1.2 and 3).

Nl-EOP-4. 1

Primar

Containment Ventin

Draft Revision

Sketches

of major components

and flow paths

are included

as figures in

procedure

Nl-EOP-4. 1.

A review of the figures resulted

in several

findings.

Nine figures

showed

the wrong flow paths.

Six figures did not

have titles and/or figure numbers.

The figures were noted to be.

0

Attachment

B

2.

3.

incorrectly drawn (locations of piping connections)

when compared to the

system piping diagrams.

The licensee

stated

the figures were to be

c'orrected

by the time the procedure

is approved.

The

NRC inspector

noted that the flow path figures

do not'rovide the

level of detail

needed during the performance of the procedure

and were

making the procedure

more voluminous.

For example,

more valves are

operated

than are

shown

on the figures.

The l,icensee

believes that the

figures are operator

aids,

intended to show major flow paths only.

The words "Good" and "Bad" should

be added to figure .shown

on page

12, to

agree with figure N1-EOP-4.4

shown

on Nl-EOP-4.

Numerous

steps

reference

a pressure

meter that has engineering units of

psi,

when the procedure

requests

readings

in units of psig.

6.

'.

Verification of automatic valve repositioning

should

be added to steps

2.4.2

and 4.4.2.

Certain valves automatically close

when the fan is

manually stopped.

The performance

of steps

6.0.b

and c appears

unnecessary

for the procedure

section (drywell and torus air purge).

Steps 6.3.2

and 8.2.2 are similar in intent, but are worded different to

steps

5. 1. 16. 2 and 5. 1. 16.3.

Other items noted during review of Nl-EOP-4.1 include typographical

errors,

control

room switch positions

worn off the switches,

and

component/control

room labeling inconsistencies.

Nl-OP-5

Control

Rod Drive

S stem

Revision

23

Section

G.26

Alternate

Boron In 'ection

Step 26.e directs operators

to add 2770 lbs of borax and

2695 lbs of boric

acid to the demineralized

water storage

tank.

Following an inspection of

the

NNP-1 and

2 warehouses, it was determined

the licensee

did not have

the proper

amount of borax and boric acid in stock.

The Unit

1 warehouse

did not have

any in stock,

the Unit 2 warehouse

had

900 lbs of boric acid

and

1000 lbx of borax in stock,

and

an offsite warehouse

(Lakeshore)

had

approximately

450 lbs each in stock.

The licensee

had approximately half

the boric acid and borax needed

to perform step 26.e.

2.

3.

Specific instructions

on physically

how to add the borax

and boric acid to

the demineralized

water storage

tank were not provided in Nl-OP-5.

In step 26.g,

two valves

(CS-47,

CS-50) are listed with the wrong plant

nomenclature.

1

Attachment

8

4.

The licensee

should reconsider

the method

used for alternate

boron

injection.

The use of RMCU or HPCI,

and not

CRD pumps,

to inject boron

should

be considered.

This will allow the operators

to continue to use

the

CRD system to insert

any rod not full in during an

ATNS.

Nl-OP-12

Li uid Poison

S stem

Revision

16

1.

System

shutdown or restoration

instructions

should

be provided in section

H.4.

The step re-aligns

the liquid poison

pump suction to the

demineralized

water storage

tank.

Instructions

on when to stop the

pump

and

how to re-align the system to the poison tank are not provided.

0

ATTACHMENT C

HUMAN FACTORS

REVIEW EXAMPLES

The following examples

-are provided to clarify the types of problems identified

in the areas

of human factors

concerns

described

in section

7 of this report.

These

examples

are not intended to be viewed .as

an inclusive list of all such

problems

found in the

NMP-1 EOPs,

but rather

as limited examples of the types

of inadequacies

identified through the

human factors analysis.

1)

Transitions

Because

of the potential for confusion

and delay inherent in transitions, it is

particularly important that transitions

be minimized.

The

NMP-1

EOP Writer'

Guide identifies

seven

acceptable

forms of transition directions including two

forms of "cross-referencing."

The distinction between cross-referencing

and

a

procedural

reference

is not clearly described within the writer's guide,

and

the other methods

provided are not necessarily

required for clear transition

direction.

For example,

"continue in this procedure

at ..." and "return to..."

could both easily

be directed

under

the term "go to."

In addition to the

multiple forms approved

in the writer's guide,

the procedures

also include

a

number of non-approved

terms, for example:

execute

(EOP 3, steps

6.5 and

6.4.6;

execute concurrently

(EOP 3, step 6.3); refer to

(EOP 3, 4.2

~ 1, 4.5.3,

4.5.4);

in step

(EOP 3, 4.3).

In addition, the qualifier "of this

procedure" called for in the writer's guide is not consistently

used within the

procedures

(EOP 3).

Critical to easy transi tioning in

EOPs is

a clear

and consistent

step

numbering

system.

Due to the attempt to match

EOP steps

in both text and flowchart

formats,

the flowcharts include several

unnumbered

or multi-numbered

steps.

This system

makes transitions difficult and can

lead to confusion

and error.

For example,

steps that are referenced

cannot

be clearly identified when

lacking

a step

number.

Evidence

was found of references

to an incorrect step

because

the correct step

lacked

a

number

(EOP 2, flowpath B, reference

to step

3.3.4 should

be to the step following 3.3.4).

In addition, the lack of step

numbers

led to the identification of several

flowpaths in

2 by letters

("A," "B," and "C").

This system deviates

from writer's guide directions.

Placekeeping

methods play an important role in preventing error and delay

during the execution of EOPs.

While use of a grease

pencil

down the flowpath

is an effective way to keep track of movement through the procedures,

the

lack spaces for placekeeping

marks with lists in the flowcharts

and with each

step in the text procedures.

The symbols

used in flowcharts provide

a useful

method for conveying

information graphically, that is, the meaning identifed with the

shape of each

symbol.

The

NMP-1 flowcharts fail to take advantage

of a specific transition

symbol, instead

embedding transitions

in symbols

used for action steps

and

override steps.

2) Oecisions

Because

of the difficult nature of decision

making during emergencies, it is

.

important the decisions

be clearly identified and simply structured.

In

flowcharts, decisions

are designated

through

use of decision

symbols

and

decision tables.

However,

in the

NMP-1 flowcharts,

a number of decisions

are

l

ann

a

I

Attachment

C

embedded within other steps,

such

as action steps,

leading to

a potential for

confusion

and error (e.g.,

EOP 3, 5.2 and 6.4.5;

EOP 2, 3.2).

The format of decision tables

can serve to clearly identify a required decision

to the operator.

In the

NMP-1 flowcharts, decision tables requiring "IF, AND,

THEN" logic are formatted identically to decision tables

requiring

"BEFORE,

IF,

THEN" logic.

Especially

when these

tables

are placed contiguously in

flowpaths,

the potential for error and delay is increased.

Related to the problem of "BEFORE, IF, THEN" decision tables,

is the identifi-,

cation of non-logic terms

as logic terms in the

NMP-1 writer's guide.

"BEFORE," "UNTIL," and

"EXCEPT" are not formal logic terms, yet are defined

and

used

as

such in the

NMP-1 writer's guide

and

This misuse

increases

the

complexity of decision

steps

and could lead to error.

Steps

including these

terms

should

be rewritten to utilize actual logic terms (use of "WHEN,THEN" in

place of "UNTIL") or to add

a note

when providing qualified supplemental

pinformation ("EXCEPT" introduces

a qualifier).

a

V

Decision tables

can increase

the

ease with which decisions

are

made or,

when

incorrectly formatted,

can disrupt flow of information. In the

NMP-1 EOPs,

some

decision tables

are formatted in extreme widths.

This format style causes

difficultly in tracking the information flow within the table

and can lead to

confusion

and error

(EOP 2;

EOP 3).

3) Cautions

and Notes

Because of the critical nature of information contained

in cautions, it is

particularly important that they be (1) properly emphasized

to catch the

operators attention,

and (2) distinguished

from the non-criti.cal information

contained

in notes.

In the

NMP-1 EOPs,

cautions

and notes in the flowcharts

are

emphasized

in exactly the

same

manner.

It is also not clear that all

cautions

state the potential

consequence

of the identified hazard,

Some cautions

and notes

are located within action steps

or following the step

to which they apply.

In all cases,

cautions

and notes

must precede

the step to

which they apply.

EOP-1,

General

Instructions consists of some cautionary

and

supplemental

information that is more appropriately

placed in the flowpath

prior to the step to which it applies.

Placement

of such important information

on

a separate

chart increases

the number of transitions

required in the

procedures

and can

cause

the operator to miss critical information,

4) Miscellaneous

A number of miscellaneous

inadequacies

were identified in the

NMP-1

EOP system.

Some are:

a)

A number of steps

are "hybrids," combining two different types of symbols,

for example,

combination caution, action step

and decision table

(EOP 3, step

3-4.4 and 4.5.2-4.5.4)

or combination override step

and decision table

(EOP

step 6.2-6.4).

This. method of combining symbols

can lead to operator error

d diminishes

the meaning

conveyed

by each type of symbol.

C

4$

Attachment

C

b)

The size of each

type of symbol is inconsistent

across

procedures.

In

addition,

type size varies

from procedure

to procedure.

Not only does this

lack of restrictiveness.

have the potential for operator confusion

and delay,

but

a lack of control over type and

symbol

size could lead to unreadable

procedures.

In addition,

the smaller type size found on several

flowcharts

(e.g.,

EOP 4,

and

EOP 6) appears

to be below minimum human factors engineering

standards.

c)

The writer's guide states that general

functions will be presented

as

steps,

with more detailed instructions prescribing specific actions through

which

a step is accomplished

presented

as

substeps

(section 4.3,

step 4).

However,

a number of action steps

in the flowcharts combine

a general

function

step with its substeps

in a complex direction, rather than using the short,

simple forms called for in the writer's guide section 4.3.,

steps

3 and

5

(e.g.,

EOP 3, steps 4.2.2,

4'.3,

and 4.5.4).

d)

The writer's guide provides

a table of standard

nomenclature

and

definitions for use in the procedures.

This table is not applied consistently

throughout the procedures.

For example,

the table identifies the verbs "start"

and "execute" to direct performance of an action or step.

However, the

also

use the verbs "initiate" and

"commence"

(EOP 3).

e)

Yes/no exits from decision

symbols

on the flowcharts were inconsistently

placed.

f)

The format for entry conditions defined in the writer's guide is not

applied in the flowcharts.

g)

The writer's guide states

that

a horizontal line wi 11

be used to separate

related action steps within one action step

symbol.

The use of the horizonal

lines is inconsistently applied throughout the

h)

The use of dotted lines in the flowcharts is not defined in the writer'

guide

and appears

to be inconsistently

used within the